Hamstring Muscle Syndrome
Ross Hauser, MD
In this article Ross Hauser, MD explains treatment options for Hamstring Muscle Syndrome.
The hamstrings are the muscles running down the back of the thighs. They are responsible for bending the knee and extending the hip, and are used most when running, especially at speed.
Tight hamstring muscle syndrome, also known as simply hamstring syndrome, is a postural abnormality seen with spondylolisthesis, which is the dislocation of a vertebra.
It is also a complaint among some athletes who participate in sports that involve rapid acceleration and short, intense sprinting, such as hurdlers, skaters, and hockey, tennis and baseball players.
- The cause of tight hamstring muscle syndrome is most likely due to the pinching of the nerve that extends to the hamstring muscle because of the dislocation of the vertebrae.
- Another theory is that it is a postural compensation for the displacement of the disc.
- And finally, it can involve ligament weakness that puts excessive stress on the hamstring muscle.
RICE not effective for Hamstring Syndrome
Medical treatment of hamstring muscle syndrome typically involves at least part of the RICE protocol, rest, ice, compression and elevation. Although some of these treatment components do bring some initial relief from muscle injuries, research evidence shows that “ice application or topical cooling does not enhance and appears to delay the return to normal of muscle damage markers and subjective fatigue feeling after eccentric exercise.”1 In other words, RICE actually hinders the healing of muscle tissue. Even the inventor of the RICE protocol is now saying both ice applications and rest delay muscle healing. Ice applications also cause muscle damage, because the hemodynamic fluctuation from the application of ice, followed by its removal can cause the tissue to die due to lack of blood flow.2
Hamstring stretches are another typical treatment, however, passive stretching without accompanying muscle strength can do more damage and lead to more injuries and pain problems.
Another standard practice is the use of steroids and anti-inflammatory medications. However, side-effect of steroid injections and their soft-tissue damaging properties have been well documented in the medical literature.
Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration. Plus, long-term use of these drugs can lead to other sources of chronic pain, allergies and leaky gut syndrome.
Please see our article on how RICE therapy has been clearly shown to hinder ligament and tendon healing.
Hamstring Muscle Syndrome, Buttock Pain and High Hamstring Tendinopathy
From a regenerative medicine perspective, the preferred long term solution is to strengthen the fibro-osseus junction of the ischial tuberosity, a point of attachment for the hamstring muscles with regenerative soft-tissue treatments such as Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy. These injection treatments stimulate repair of the buttock pain and posterior thigh pain.
Pain deep in the buttocks or upper back-side of the thigh can be due to tendon injury near the origin of the hamstring muscle off of the ischial tuberosity. That is the name of the bone which bears body weight in the seated position. It is an injury we see in mid to long distance runners, yoga practitioners, and occasionally non-athletic individuals who have been injured by improper chiropractic adjustments or physical therapy.
Occasionally the damage to the tendon in chronic cases can be severe enough to cause irritation of the nearby sciatic nerve, thus producing symptoms of referred pain down the entire back of the leg which are more typically associated with herniated lumbar disks.
The pain is worse when the patient is seated on a hard surface, and after running, especially at faster speeds. There can be pain at rest in severe cases. The bent knee stretch test is applied for the diagnosis of this condition with the patient lying supine. The hip and knee are first maximally flexed towards the patient’s chest, and then the knee is extended gradually. Pain at the origin of the hamstring on that side which reproduces the patient’s pain is diagnostic. Additionally, a diagnosis for injection treatments such as Prolotherapy relies on direct thumb pressure over the proximal hamstring tendon in the buttocks, the so called “jump sign” to reproduce the pain, localize the injury, and determine the best treatment. Direct firm pressure on affected areas causes the patient to “jump’ because of accentuation of the pain. Finally, injection of a local anesthetic solution into the tendon-bone junction of the affected hamstring tendon can cinch the diagnosis by immediately eradicating all evidence of pain at rest or with motion or sitting.
There are several other conditions that can produce a similar symptom complex. Herniated lumbar disks and sacroiliac ligament strain both refer pain into the deep buttock area. Spasm of the pyriformis muscle is another common condition in athletes, and in older individuals metastatic cancer to the bone, and pelvic stress fracture must also be considered. Fortunately, all of these conditions except for the latter two will respond to appropriately applied Prolotherapy, but making the differential diagnosis is critical in order to achieve the most rapid response. When necessary, X-rays, bone scan, or MRI imaging is ordered.
Prolotherapy injections are definitely the fastest route to recovery from high hamstring tendinopathy. The only possible danger from prolo for this disorder is the proximity of the hamstring tendons to the sciatic nerve, but proper experience and technique will always avert any problems in this regard. Should the nerve ever be touched by the slowly advancing prolo needle (a precautionary measure on the prolotherapist’s part), there will be a quick electrical sensation down the leg. As the needle is withdrawn or redirected, any discomfort will be mild and temporary.
Platelet Rich Plasma Therapy
In recent research doctors note that while hamstring injuries can be disabling, and several traditional conservative treatments, including physiotherapy and nonsteroidal anti-inflammatory drugs, have been inconsistent and corticosteroid injections have demonstrated success but can adversely affect local tissues, it is Platelet-rich plasma (PRP) that emerged as a safe, effective treatment. In a study that yielded 15 patients with 17 hamstring injuries. Twelve injuries failed traditional conservative treatment and were ultimately treated with a PRP injection at the hamstrings muscle origin. The PRP group showed significant improvement, the conservative treatment group did not.3
In a study to see which technology could better detect corticosteroid injections success, an MRI or ultrasound, the researchers found “Fifty percent of patients had symptomatic improvement lasting longer than 1 month after percutaneous corticosteroid injection, and 24% of patients had symptom relief for more than 6 months.”4 In other words, the typical conservative treatment of cortisone is not a guaranteed cure for this hamstring injury.
What these researchers found is what Prolotherapy doctors have long known: a better approach to hamstring injury is to strengthen the fibro-osseus junction of the ischial tuberosity with Prolotherapy. The ischial tuberosity bears body weight in the seated position and is a point of attachment for the hamstring muscles. In the above research, Platelet Rich Plasma injection was used at the “muscle origin” the fibro-osseus junction.
1.Tseng CY, Lee JP, Tsai YS, Lee SD, Kao CL, Liu TC, Lai C, Harris MB, Kuo CH. Topical cooling (icing) delays recovery from eccentric exercise-induced muscle damage.J Strength Cond Res. 2013;27(5):1354-61. doi: 10.1519/JSC.0b013e318267a22c.
2. Malone T, Engelhardt D, Kirkpatrick J, Bassett F. Nerve injury in athletes caused by cryotherapy. J Athl Train. 1992; 27(3): 235–237.
3. Wetzel RJ, Patel RM, Terry MA. Platelet-rich Plasma as an Effective Treatment for Proximal Hamstring Injuries. Orthopedics. 2013 Jan 1;36(1):e64-70. doi: 10.3928/01477447-20121217-20.
4. Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol. 2010 Oct;195(4):993-8. doi: 10.2214/AJR.09.3674.